Wednesday, March 27, 2019

Professional discussion about
preventing sexual abuse is often couched in absolutes, especially when it comes
to anti-social behavior. In our field, we often talk about eliminating abuse
and/or stopping people from abusing, whether before it starts or after it has
occurred. We find ourselves asking… is it really that easy? It is striking how rarely
our discussions focus on harm reduction or how we might influence the nature of
offending, offenses, or reconviction. By thinking in absolutes, we may be
cutting ourselves off from innovative research and treatment practices.

Ultimately, all of our efforts are
aimed at moving an individual from one end of a spectrum (offending) to the
other end (desistence) in a short, often pre-determined time. In reality,
meaningful behavior change takes time, faces unpredictable challenges, and has
its stumbling blocks; genuine change can be a messy process. All of this begs
the question of whether we are setting ourselves up for failure when we recognize
only black or white in the management and treatment of people who sexually
offend?

A client treated by the second author
(David) many years ago serves as an example. This young man entered treatment
after an extremely serious sex crime. After nearly two years of treatment, he
re-entered the community where he lived safely for one year. He then committed a
lesser property crime. It was at that point that he realized what lay ahead in
his future if he didn’t make even deeper changes. He lived offense-free as a
stable and occupied person for many years thereafter. What can we make of this
trajectory? Some would believe that his subsequent arrest is an indication that
treatment didn’t work. Others would be encouraged by the fact that the severity
of his behavior had decreased significantly. He would be coded as a recidivist
in some studies but not those focusing solely on sexual re-offense. We believe
his case highlights how a harm reduction perspective can be helpful.

Harm reduction policies and practices
build upon the notion that people desist from specific harmful behaviors one
step at a time, are guided in that process by professionals and the system is
set up in a way that enables positive change. In many respects harm reduction
policies are very closely linked to the notion of quaternary prevention (that
is, actions taken to protect individuals from interventions that are likely to
cause more harm than good). This approach is built on the understanding that behavior
change takes time. Harm reduction can be a perspective, approach, or outcome. The
key element is that the person in questions stops most damaging behavior and
engages in a process of working on their other problematic behaviors
systematically. A focus on reducing harm or the most problematic behavior, at
the expense of other behaviors, is not an excuse for offending or an
apology for it. It is a central part of many criminal-justice approaches (such
as with youthful offending), health care (for example, drug addiction) and mental
health treatment populations. Yet harm reduction is not fully embraced when it
comes to working with people who commit sexual abuse.

In treating addictions, professionals
do not expect a heroin addict to stop completely overnight. Instead, they
consider intermediate approaches such as Methadone or Suboxone. Likewise, with
alcohol abuse we talk about reducing an individual’s daily intake and enabling
them to cut down their dependence over time. When it comes to the field of
sexual abuse, the expectation placed on those who have abused is that they must
recognize and eradicate every aspect of their problematic behavior overnight. In
some areas, even minimizing the harm of one’s actions has been enough to deny
entry into treatment programs. Keeping people out of treatment doesn’t make
them less likely to cause harm.

Practitioners in our profession don’t
talk in terms of reducing harm, especially from a policy, political and public
view; instead we often talk about complete and immediate harm eradication. This
is likely because the narrative surrounding the reduction of harm in regard to
people who commit sexual offenses can be (and often is) misconstrued as an
absolution for problematic behavior. Harm reduction requires nuanced thinking
and practical approaches, and too often flies in the face of our more absolute
ideals.

Recalling the earlier example, yes, he
still committed an offense and still displayed problematic behaviors. However,
the level of harm was reduced substantially. This does not justify his property
crime, but history showed it to be a lesser crime on the road to desistance.

It seems worth mentioning that the
recent evaluation (2017)
of the prison-based Core Sex Offender Treatment Programme in the UK (which
ultimately lead to its being abandoned) demonstrated a reduction in harmful
behavior by participants. Within the outcomes, it found that there were a group
of service users that were reoffending, but not at the same level or in the
same fashion that they originally offended. Asking questions about the nature
and use of interventions that contributed to de-escalation of these people’s
offenses, and the time frames in which they took place would have been helpful.

Likewise, Karl Hanson recently spoke
at the ATSA conference about how risk is dynamic. He argued that with the
correct support and interventions, risk can drop from high to low over a 20-year
period. All of this begs the question, how long does behavior change take and
what does the journey look like?

Forensic
evaluators may be assisted by comparing their use of instruments with that of
their peers. This article reports the results of a 2017 survey of instrument
use by forensic evaluators carrying out sexual recidivism risk assessments.
Results are compared with a similar survey carried out in 2013. Analysis
focuses primarily on adoption of more recently developed instruments and norms,
and on assessment of criminogenic needs and protective factors, and
secondarily, on exploring factors related to differences in evaluator practice.
Findings indicate that most evaluators have now adopted modern actuarial
instruments, with the Static-99R and Static-2002R being the most commonly used.
Assessment of criminogenic needs is now common, with the STABLE-2007 being the
most frequently used instrument. Evaluators are also increasingly likely to
consider protective factors. While a majority of evaluators uses actuarial
instruments, a substantial minority employs Structured Professional Judgment
(SPJ) instruments. Few factors discriminated patterns of instrument use.

Contemporary
surveys of practitioners who complete sexual risk assessments are important for
researchers, evaluators, and decision-makers. Researchers benefit from staying
informed of what methodologies are actually being implemented in practice in
order to consider whether additional research or more effective strategies of
communicating research results are needed. Decision-makers such as courts need
to have objective data to help guide their understanding of what results should
be taken under consideration and how much weight it should be given (e.g.,
admissibility issues). My colleagues and I also noticed that evaluators in
different settings/jurisdictions tended to develop their own norms and culture
regarding what is considered common risk assessment methodology, but we
wondered how that might translate into the larger field. We also found that
while other surveys provided useful information, we were interested in factors
that had not yet been examined such as use of old versus new static
instruments, use of criminogenic needs instruments, and how evaluators chose to
communicate the results of such instruments.

What kinds of challenges did you face throughout the process?

We initially
had the idea to conduct a survey in 2013, but we chose to add a few survey
questions to a larger study on evaluator decision-making that we were
conducting at the time. As a result, the information we obtained was fairly
limited. However, the process allowed us to better consider the questions we
wanted to know, and we set to work designing an independent research project. Designing
survey questions is actually more difficult than it appears. In 2017, we spent
a considerable amount of time designing the survey and deliberating on the
wording of the questions. Even so, after the data was collected and analyzed we
recognized the need for additional questions or how existing questions could
have been re-worded to better understand the results. Obtaining participation
is also a challenge with online surveys. Getting formal approval to utilize the
ATSA-listserv and American Psychology – Law Society (AP-LS) email distribution
list was important in achieving our results. However, future surveys will need
to get formal approval to reach international forensic professional groups as
well.

What do you believe to be the main things that you have learnt about the
professional practices in assessing Sexual Recidivism Risk?

Overall, most
practitioners are modifying their methodology to keep up with research advances
including using newer static and criminogenic needs instruments as well as
communicating risk results based on current norms. However, there continues to
be practitioners using older static instruments (e.g., RRASOR) as well as
outdated norms associated with these instruments. Divergence was notable in how
evaluators appear to be choosing the Static-99R normative group (i.e.,
Routine/Complete vs. High Risk/Needs groups) and their use of a criminogenic
needs measure to assess for dynamic risk factors and treatment change. Within
the sample, about 22% reported not using a criminogenic needs instrument due to
concerns that the research was insufficient to support its use and concerns about
the adequacy of the norms. Similarly, of those who reported that measuring
treatment gains was relevant to their work, a third did not use a formal
instrument to assess for treatment progress. This divergence did not appear
clearly related to educational activities, years of experience, and freedom in
selecting their own instruments. However, the tendency to only use the
Routine/Complete Static-99R norms was associated with evaluators working in
private practice regardless of the setting in which they worked (e.g.,
outpatient vs. forensic commitment).

Now that you’ve published the article, what are some implications
for practitioners?

While we were unable to
ascertain why some practitioners continue to use older measures and norms, we
did identify concerns related to new measures of dynamic risk and treatment
need. Frequent concerns were related to a lack of research demonstrating their
validity and reliability, concerns about the instruments’ norms, and the belief
that no existing measure can predict a reduction of sexual recidivism due to
treatment change. Ultimately, the decision to adopt measures and make changes
to one’s methodology will be based on demands of the environment and evaluator
standards, and this will be different between jurisdictions and practitioners. Our
concern is the possible tendency of overlooking or discounting new research
findings and becoming comfortably “stuck” in old practices. As such, we
emphasize that a good standard of practice would involve making a priori
determinations of what one would need (e.g., research or norms), staying
informed of research advances, and then changing methodology once the predetermined
criteria are met. Such determinations should also be consistent with
professional guidelines (i.e., Section 6.08 of the 2014 ATSA Adult Practice
Guidelines). Use of forensic checklists can be important in determining when to
start or stop using an instrument. I strongly suggest utilizing a checklist or
table to track the pros and cons for each instrument under consideration, and
to modify this document over time as research advances. I have provided an
example of what I termed an Informed Decision-Making Table, which readers will
be able to retrieve by contacting me at SharonM.Kelley@dhs.wi.gov.

Thursday, March 7, 2019

Note: This will also be
reposted on Scott’s own blog site
as well. Kieran

Several
weeks ago, the American Psychological Association (APA) released its latest in
a series of practice guidelines for psychologists – this time for “Psychological
Practice with Boys and Men.” Prior years had seen guidelines focused on ethnicity,
older adults, girls and women, LGBT, and “transgender and gender-non-conforming”
persons.

Curiously,
despite claiming to be based on 40 years of research, and the product of 12
years of intensive study, the latest release attracted little attention.More, the responses that have appeared in
print and other media have largely been negative (1, 2,
3, 4,
5).

What
happened?

At
first blush, the development and dissemination practice guidelines for
psychologists would seem a failsafe proposition.What possibly could go wrong with providing
evidence-based information for improving clinical work?And yet, time and again, guidelines released
by APA end up not just attracting criticism, but deep
concern. Already, for
example, a Title
IX complaint has been filed against the new guidelines at Harvard.

Consider others released in late 2017 for the treatment of trauma.Coming
in at just over 700 pages ensured few, if any, actual working professionals
would read the complete document and supportive appendices. Beyond length,
the way the information was presented–especially the lack of hypertext for
cross referencing of the studies cited–seriously compromised any straightforward
effort to review and verify evidentiary claims.Nevertheless, digging into the details
revealed a serious problem:none of the specific approaches “strongly recommended”
in the guidelines had been shown by research to be more effective than any
other.

Guidelines are
far from benign.They are meant to shape
practice, establishing a “standard of care” -- one that will be used, as the
name implies to guide training and
treatment.As such, the stakes are high,
potentially life altering for both practitioners and those they serve.

And so, on reading the latest release from the
APA, we wonder about the
consequences for men and boys.Even a
superficial reading leaves little to recommend “being male.”Gone are any references to
the historical or current contributions of men -- to their families,
communities, marginalized peoples, culture, or civilization.In their place, are a host of sweeping generalizations often wrapped in copious amounts of
politically, progressive jargon on a wide variety of subjects, many of which
are the focus of research and debate by serious scientists (e.g., the
connection between media violence and male aggression, socialization as a
primary cause of gender and behavior, the existence of a singular versus
multiple masculine ideal, etc.).

Cutting to the chase, when viewed in this way,
is it any wonder really, that many men – as the document accurately points out
– “do not seek help from mental health professionals when they need it?” (p.
1).

And lest there be any doubt, men as a group, are
in need help.

You’ve likely read the statistics, seen
examples in your practice, perhaps in the life of your family or friends.It starts young, with boys accounting for
90% of discipline problems in schools, and continues to the end of life, with
women living 5 to 10 years longer on average.The “in between” years are not any better, with men significantly more
likely to be incarcerated, addicted to drugs, drop and fail out of school, and end
their lives by suicide.

To be clear, the
document is not overarchingly negative.At the same time, if our goal, as a profession, is to reduce stigma -- which previous, and even the present, guidelines
do for other groups and non-traditional males -- then the latest release risks perpetuating
stereotypes and prejudices of “traditional” men and the people in their orbit.

Sticking to the science of
helping, instead of conforming to popular standards of public discourse, would
have lead to a very different document – one containing a more nuanced and
appreciative understanding of the boys and men who are reluctant to seek our
care.In the fractious times in which we
find ourselves, perhaps it’s time for guidelines on how to live and work together,
as individuals and as a species.

Kieran McCartan, PhD

Chief Blogger

David Prescott, LICSW

Associate blogger

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The Association for the Treatment of Sexual Abusers (http://atsa.com/) is an international, multi-disciplinary organization dedicated to preventing sexual abuse. Through research, education, and shared learning ATSA promotes evidence based practice, public policy and community strategies that lead to the effective assessment, treatment and management of individuals who have sexually abused or are risk to abuse.

The views expressed on this blog are of the bloggers and are not necessarily those of the Association for the Treatment of Sexual Abusers, Sexual Abuse: A Journal of Research & Treatment, or Sage Journals.

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